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APPLICATION. (� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES \ ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .(Complete in Triplicate) Application is hereby made to San Joaquin County for a,permit to conetruct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and. 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address %d42 E. Baker Lane City Lindell Lot Size/Acreage Owner's Name �' & A Lagomarsinb Address 16042 E. Baker, Linden .. Phone AMOUNT REMITTED V Contractgtlryiance Drilles,Il dlttass P.O. ,Box 64,LindenJLicQ& No. _3119-23— Phone is 8 TYPE OF WELL/PUMP: NEW WELL3t WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well Cl LFF PUMP INSTALLATION] SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing 12 114' C7 Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications-- , 188 I'1 Public 1:1 Other fl Delta Depth'of;Grout Seal r d�� Type of Grout LX Irrigation eJ ;z..a Approx. Depth I I Eastern _ Surface `Seal Installed by Repair Work Done U Type of PumpT trrh H.P. 40: ', ` a State Work Done Well Destruction.. S;❑ . Well Diameter _ Sealing' plate"ria l i Depth Depth - ` Filler Material &` Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 l REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence' Commercial ___ Other Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ,Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ "No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size „ Number _. SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application, andthat the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "ecertify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." . . ' , The plicant m t call,f�re�inspq�ctio�ns,omplete drawing on reverse side. Signed�r Title: (I-OY' SeCx'etn-ry Date: _ Application Accepted by Pit or Grout spection by Additional Comments: _ Applicant - Return all copies FOR DEPARTMENT USE ONLY Date 1— 7__Area _C) I�I n by VV 4, 1f)4 Date . EH 13-24 IREV. tixsi EH 14.20 San Joaquin County Public 'Health Sery Environmental Health Permit/Services. 445 N San Joaquin, P O Box 2009, Stkn ices�� dr b^ CA 95201 /F G N P F 14 AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATEEEERMIT'NO. LFF 2,12, b G N P F 14